This chapter establishes the requirements for the Medicaid Hospice Program in Texas, both for hospices contracting with the Department of Aging and Disability Services to provide hospice services and for Medicaid-eligible individuals who elect the Medicaid Hospice Program.
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. Individual subchapters may have definitions which are specific to the subchapter.
(1) Adverse action — As defined under §79.1601 of this title (relating to Definitions).
(2) Attending physician — A physician who:
- is a doctor of medicine or osteopathy; and
- is identified by the individual, at the time the individual elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.
(3) Bereavement counseling — Counseling services provided to the individual's family after the individual's death.
(4) Cap period — The 12-month period ending October 31 used in the application of the cap on overall hospice reimbursement specified in §30.60 of this title (relating to Medicaid Hospice Payments and Limitations).
(5) Curative care — Care designed to restore a person to health.
(6) Employee — An employee (defined by the Social Security Act, Section 210(j)) of the hospice or, if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is appropriately trained and assigned to the hospice unit. "Employee" also refers to a volunteer under the jurisdiction of the hospice.
(7) Hospice — A public agency or private organization or subdivision of either of these that is primarily engaged in providing care to terminally ill individuals.
(8) Palliative care — Care designed to relieve or reduce intensity of uncomfortable symptoms but not to produce a cure.
(9) Physician — As defined in 42 Code of Federal Regulations §410.20.
(10) Representative — An individual who has been authorized under state law to terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill individual who is mentally or physically incapacitated.
(11) Social worker — A person who has at least a bachelor's degree from a school accredited or approved by the Council on Social Work Education.
(12) Terminally ill — The individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.
(13) Vendor hold — Temporarily withholding a provider agency's payment.
(a) In order to be eligible to elect hospice care under Medicaid, an individual must:
- be certified as Medicaid eligible by the Texas Department of Human Services (DHS) or the Social Security Administration (SSA);
- be certified as being terminally ill in accordance with §30.14 of this title (relating to Certification of Terminal Illness); and
- have an identified need documented on the comprehensive assessment for one or more of the following:
- medical care;
- skilled nursing care related to the management of pain and symptom control;
- medical social services; or
- emotional or spiritual care.
(b) If dually eligible, the recipient must elect the hospice benefit under both the Medicare and Medicaid programs.
(a) Subject to the conditions set forth in this subchapter, an individual may elect to receive hospice care for a six-month period.
(b) The periods of care are six-month increments of time and may be elected consecutively or separately at different times.
(a) Timing of certification.
- The hospice must obtain the oral certification of terminal illness from a physician no later than two calendar days after the period begins.
- For the initial period, the physician(s) must sign and date the Medicaid Hospice Program Physician Certification of Terminal Illness form before the hospice submits an initial request for payment. The physician must sign and date the Medicaid Hospice Program Physician Certification of Terminal Illness form in all cases before the expiration date of each six-month certification period. Forms must be submitted by the hospice as outlined in §30.62 of this chapter (relating to Medicaid Hospice Claims Requirements) and must be submitted beforebilling.
(b) Content of certification. The certification must specify that the individual's prognosis is for alife expectancy of six months or less if the terminal illness runs its normal course. The certification statement must be based on record review or consultation with the referring physician.
(c) Sources of certification. For the initial period, the hospice must obtain written certification statements, and oral certification statements if required under subsection (a)(2) of this section, from:
- the medical director of the hospice or the physician member of the hospice interdisciplinary group; and
- the individual's attending physician if the individual has an attending physician.
- Upon receipt of the certification, hospice staff must:
- for oral certification:
- make an appropriate entry in the patient's medical record as soon as they receive an oral certification;
- notify the nursing facility or the intermediate care facility for persons with mental retardation or related conditions (ICF/MR-RC) of oral certification, when applicable; and
- file written certifications in the medical record.
- for oral certification:
- Documentation must include the name of the physician who makes the oral certification and the date it was received. The individual who makes the entry into the recipient's record must sign and date the entry.
(e) Client-specific assessment.
- For subsequent periods after the first year, the hospice must conduct a client-specific comprehensive assessment that:
- identifies the client's need for hospice services in the areas of medical, nursing, social, emotional, and spiritual care. Hospice services include, but are not limited to, the palliation and management of the terminal illness and conditions related to the terminal illness; and
- contains a narrative from the physician which clearly identifies the reasons the patient is considered terminally ill; with a prognosis of less than six months to live.
- The assessment must be done no earlier than 30 workdays prior to the recertification date.
(f) Record maintenance. The hospice provider must retain copies of all physician certification statements, a current Minimum Data Set (MDS) assessment or current level of need (LON) assessment, if applicable, and the client-specific comprehensive assessment in the recipient's records at the hospice and the nursing facility clinical record or ICF/MR-RC client record, if applicable.
(a) Filing an election statement. An individual who meets the eligibility requirement of §30.10 of this title (relating to Eligibility Requirements) may file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, the individual's representative may file the election statement. If the recipient is dually eligible for Medicaid and Medicare, the individual must elect the Medicaid and Medicare hospice benefit at the same time.
(b) Content of election statement. The election statement must include the following:
- identification of the particular hospice that will provide care to the individual;
- the individual's or representative's acknowledgment that he has been given a full explanation of the palliative rather than curative nature of hospice care as it relates to the individual's terminal illness;
- acknowledgment that certain Medicaid services, as set forth in subsection (d) of this section, are waived by the election;
- the effective date of the election, which may be the first day of hospice care or a later date, but must be no earlier than the date of the election statement; and
- the signature of the individual or representative.
(c) Duration of election. An election to receive hospice care will continue through the initial election period and through the subsequent election periods without a break in care as long as the individual:
- remains in the care of a hospice; and
- does not revoke the election under the provisions of §30.18 of this title (relating to Revoking the Election of Hospice Care).
(d) Waiver of other benefits. For the duration of an election of hospice care, an individual waives all rights to Medicaid payments for the following services:
- hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice); and
- any Medicaid services related to the treatment of the terminal condition for which hospice care was elected, or a related condition for which the hospice care was elected, or that are equivalent to hospice care except for services:
- provided by the designated hospice;
- provided by another hospice under arrangements made by the designated hospice; and
- provided by the individual's attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services.
(e) Re-election of hospice benefits. If an election has been revoked in accordance with§30.18 of this title (relating to Revoking the Election of Hospice Care), the individual (or the individual's representative, if the individual is mentally or physically incapacitated) may at any time file an election in accordance with this section.
(f) Record maintenance. The hospice provider must retain copies of all election forms in the hospice records for the recipient and the recipient's nursing facility clinical record, or the intermediate care facility for persons with mental retardation or related conditions (ICF/MR-RC), if applicable.
(a) An individual or representative may revoke the individual's election of hospice care at any time during an election period. If the recipient is dually eligible, the individual must revoke the Medicaid and Medicare hospice benefit at the same time.
(b) To revoke the election of hospice care, the individual or representative must file a statement with the hospice that includes the following information:
(1) a signed statement that the individual or representative revokes the individual's election for Medicaid coverage of hospice care for the remainder of that election period; and
(2) the date that the revocation is to be effective. An individual or representative may not designate an effective date earlier than the date that the revocation is made.
(c) An individual, upon revocation of the election of Medicaid coverage of hospice care for a particular election period:
- is no longer covered under Medicaid for hospice care;
- resumes Medicaid coverage of the benefits waived under §30.16(d)(2) of this title (relating to Election of Hospice Care); and
- may at any time elect to receive hospice coverage as long as he meets eligibility requirements.
(d) The provider must submit the Medicaid Hospice Recipient Election/Cancellation/Discharge Notice to Provider Claims Services.
(a) An individual or representative may change, once in each election period, the designation of the particular hospice from which hospice care will be received. If the recipient is dually eligible for Medicaid and Medicare, the individual must change the Medicaid and Medicare hospice benefit at the same time.
(b) The change of the designated hospice is not a revocation of the election for the period in which it is made.
(c) To change the designation of hospice programs, the individual or representative must file, with both the hospice from which care has been received and with the newly designated hospice, a statement that includes the following information:
- the name of the hospice from which the individual has received care and the name of the hospice from which the individual plans to receive care; and
- the date the change is to be effective.
(d) The provider must submit the Medicaid Hospice Recipient Election/Cancellation/Discharge Notice to Provider Claims Services.
(a) A hospice participating in the Medicaid Hospice Program must comply with the requirements in this chapter and with all federal and state regulations that govern the Medicaid Hospice Program, including the federal regulations in 42 Code of Federal Regulations Part 418 (Hospice Care).
(b) To be approved by the Department of Aging and Disability Services (DADS) for participation in the Medicaid Hospice Program and be awarded a contract, a hospice must:
- ( meet the provisions described in Chapter 49 of this title (relating to Contracting for Community Care Services), except for:
- §49.13(b) and (f)(1) of this title (relating to General Contractual Requirements);
- §49.14 of this title (relating to Provisional Contracts);
- §49.15(d)(2)(B) of this title (relating to Contract Assignment);
- §49.31(e) of this title (relating to Record Requirements);
- §49.41(c)(1) and (12) of this title (relating to Billings and Claims Payment);
- §49.42 of this title (relating to Method of Payment);
- §49.43 of this title (relating to Expedited Payments System);
- §49.61(a)(4) and (11) of this title (relating to Sanctions); and
- §49.63(a), (c), and (d) of this title (relating to Recontracting);
- be licensed in Texas as a home and community support services agency to provide hospice services; and
- maintain Medicare certification to provide hospice services through the Centers for Medicare and Medicaid Services.
(c) A hospice participating in the Medicaid Hospice Program must not have restrictive policies or practices, including:
- requiring an individual to execute a will with the hospice named as legatee or devisee;
- assigning an individual's life insurance to the hospice;
- transferring an individual's property to the hospice;
- requiring an individual to pay a lump sum or make any other payment or concession to the hospice beyond the recognized Medicaid rate;
- controlling or restricting an individual or legal representative in using the individual's
- personal needs allowance while in a nursing facility or an intermediate care facility for persons with mental retardation or related conditions (ICF/MR-RC);
- restricting an individual from transferring or withdrawing from the Medicaid Hospice Program at will, except as provided by state law;
- denying appropriate hospice care to an individual on the basis of the individual's race, religion, color, national origin, sex, age, disability, marital status, or source of payment; and
- preventing or requiring the execution of written or unwritten directives to reject life-sustaining procedures by an adult individual.
(d) If a hospice provides services to a resident of a nursing facility or an ICF/MR-RC, the hospice must have a written contract for the provision of services with the nursing facility or ICF/MR-RC.
(e) DADS does not pay for hospice services provided before the date:
- the hospice has a Medicaid hospice contract with DADS;
- the individual makes a valid election of the Medicaid hospice benefit as provided under subsection (f) of this section; and
- the hospice has a contract with a nursing facility or an ICF/MR-RC if hospice services are provided in a nursing facility or an ICF/MR-RC.
(f) For purposes of subsection (e)(2) of this section, a valid Medicaid hospice election must be dated on or after the requirements listed in subsection (e)(1) and (3) of this section have been met.
(g) If a hospice assigns its contract, it must be assigned in accordance with §49.15 of this title and the hospice to which the contract has been assigned must submit an updated Texas Medicaid Hospice Program Recipient Election/Cancellation/Discharge Notice form for each individual receiving Medicaid hospice services from the hospice.
(h) A hospice must allow legal representatives of DADS, the Texas Attorney General's Medicaid Fraud Control Unit, and the Texas Health and Human Services Commission to enter the premises at any time to make inspections or privately interview the individuals receiving Medicaid hospice services.
A hospice must disclose information in accordance with 42 CFR Part 455, Subpart B.
(a) If a hospice wishes to voluntarily terminate its contract with the Department of Aging and Disability Services (DADS), regardless of the reason, the hospice must notify DADS in writing at least 10 days before the contract is terminated. The written notification must be sent to the Department of Aging and Disability Services, Community Services, Attention: Contracts, P.O. Box 149030, Mail Code W-517, Austin, Texas 78714-9030. Notification sent by overnight mail must be sent to the Department of Aging and Disability Services, Community Services, Attention: Contracts, 701 West 51st Street, Mail Code W-517, Austin, Texas 78751.
(b) At least 10 days before a hospice terminates its contract as provided in subsection (a) of this section:
- for each individual receiving Medicaid hospice services, the hospice must submit a Texas Medicaid Hospice Program Recipient Election/Cancellation/Discharge Notice form to DADS' claims processor indicating the individual has changed his designated hospice or revoked his election of hospice care; and
- for each individual receiving Medicaid hospice services who is changing his designated hospice, the hospice must ensure that a copy of the individual's active record is sent to the receiving hospice in order to ensure continuity of care and services to the individual.
(c) Submission of the Texas Medicaid Hospice Program Recipient Election/Cancellation/Discharge Notice form to DADS' claims processor is governed by §30.20 of this chapter (relating to Change of the Designated Hospice) and §30.18 of this chapter (relating to Revoking the Election of Hospice Care).
A hospice must submit by mail, fax, or hand-delivery any written information that DADS requires of the hospice. DADS does not accept e-mail delivery.
§30.40 Condition of Participation — Physical Therapy, Occupational Therapy, and Speech-Language Pathology
(a) Physical therapy services, occupational therapy services, and speech-language pathology services must be available and, when provided, offered in a manner consistent with accepted standards of practice.
(b) Lab services must be provided under the following conditions:
- If the hospice engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the FDA, such testing must be in compliance with all applicable requirements of 42 Code of Federal Regulations (CFR) Part 493.
- If the hospice chooses to refer specimens for laboratory testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and sub-specialties of services in accordance with the applicable requirements of 42 CFR Part 493.
To be reimbursed through Medicaid, hospice services must meet the following requirements:
(1) services must be reasonable and necessary for the palliation or management of the terminal illness, as well as conditions related to the terminal illness;
(2) the individual must elect hospice care in accordance with §30.16 of this title (relating to Election of Hospice Care);
(3) a plan of care must be established before services are provided. The services must be consistent with the plan of care; and
(4) a certification that the individual is terminally ill must be completed as set forth in §30.14 of this title (relating to Certification of Terminal Illness).
(a) The Health Care Financing Administration (HCFA) may approve a waiver for nursing services or occupational, physical, and speech therapies provided by a hospice which is located in a non-urbanized area. The location of a hospice that operates in several areas is considered to be the location of its central office. The hospice must provide evidence that it was operational on or before January 1, 1983, and that it made a good faith effort to hire a sufficient number of nurses or therapists to provide services directly. HCFA bases its decision on whether to approve a waiver application on the following:
- the current Bureau of the Census designations for determining non-urbanized areas;
- evidence that a hospice was operational on or before January 1, 1983, including:
- proof that the organization was established to provide hospice services on or before January 1, 1983; (B) evidence that hospice-type services were furnished to patients on or before January 1, 1983; and (C) evidence that the hospice care was a discrete activity rather than an aspect of another type of provider's patient care program on or before January 1, 1983; and
- evidence that a hospice made a good faith effort to hire nurses or therapists, including:
- copies of advertisements in local newspapers that demonstrate recruitment efforts;
- job descriptions for nurse employees or therapists;
- evidence that salary and benefits are competitive for the area; and
- evidence of any other recruiting activities, such as recruiting efforts at health fairs and contacts with nurses or therapists at other providers in the area.
(b) A waiver request for occupational, physical, and speech therapies, must be submitted in writing to Home and Community Support Services, Texas Department of Human Services (DHS), P.O. Box 149030, Mail Code E-217, Austin, Texas 78714-9030.
(c) The department will recommend in writing, approval or disapproval of the requested waiver for occupational, physical, and speech therapies, to the Health Care Financing Administration in Dallas, Texas within 30 days of receiving the request.
(d) HCFA receives requests for waivers of nursing services without the involvement of the department.
(e) Any waiver request is deemed to be granted unless it is denied within 60 days after it is received.
(f) Waivers will remain effective for one year at a time.
(g) HCFA may approve a maximum of two one-year extensions for each initial waiver. If a hospice wishes to receive a one-year extension, the hospice must submit a certification to HCFA, prior to the expiration of the waiver period, that the employment market for nurses and therapists has not changed significantly since the time the initial waiver was granted.
(a) Continuous home care. Continuous care is to be provided only during periods of crisis to maintain the recipient at the recipient's place of residence. A period of crisis is a period in which a recipient requires continuous care which is primarily skilled nursing care to achieve palliation or management of acute medical symptoms.
- A minimum of eight hours of continuous home care must be provided during a 24-hour day which begins and ends at midnight. The care need not be continuous, for example, four hours could be provided in the morning and another four hours in the evening of that day.
- Skilled nursing care must be provided for more than half of the continuous home care period and must be provided by either a registered nurse or licensed vocational nurse.
- Homemaker, home health aide services, medical social work, or chaplain services may be provided to supplement the nursing care. The provider must document why social work or chaplain services were needed and what was accomplished during continuous home care. While on-call staff may be used to provide continuous home care; staff, however, must be on site, providing care to the recipient in their place of residence to be considered for inclusion in continuous home care hours.
- The services may be provided for up to five consecutive days. The Texas Department of Human Services (DHS) may review multiple continuous home care episodes within a consecutive 30-day period.
- The provider must have a physician's order and a documented medical need for skilled nursing care in the recipient's record and in the plan of care. The plan of care must be established by the attending physician, hospice medical director or his designee, and the interdisciplinary team, and coordinated by the hospice registered nurse. The plan of care must include the needs of the recipient; identification of the services, including management of discomfort and symptom relief; and the scope and frequency of the services needed to meet the needs of both the recipient and family.
- For purposes of this section, the following definitions apply:
- Nursing services — Nursing tasks that could not reasonably be delegated to family members or nurse aides.
- Crisis — A sudden paroxysmal intensification of symptoms that appropriate medical intervention and nursing services could reasonably be expected to ameliorate.
- Prior to providing continuous home care, the provider must advise and discuss with the family or responsible party that temporary alternate placement may be necessary at the end of the five consecutive days. The provider must document the discussion with the family or responsible party in the recipient's records.
- If the provider believes that the crisis period will extend beyond the five consecutive days, the interdisciplinary team must discuss the temporary placement alternatives available to meet the needs of the recipient during the crisis period, such as a hospital or nursing facility. This discussion must be documented. If, after this discussion, the provider believes that an extension of continuous home care is necessary instead of alternative placement, the provider must submit a written request for an extension of continuous care to DHS. Faxed submissions will not be considered.
- The written request must be sent to Texas Department of Human Services, Long-Term Care Policy Section, Attention Medicaid Hospice, P.O. Box 149030, Mail Code W-519, Austin, Texas, 78714-9030. Overnight mail must be sent to the Long-Term Care Policy Section, Texas Department of Human Services, 701 West 51st Street, Mail Code W-519, Austin, Texas 78751.
- The written request must include:
- description of the specific crisis and how the provider plans to resolve the crisis;
- documentation of all continuous home care provided during the previous four days;
- physician's orders;
- documentation of daily physician care plan oversight;
- documentation that skilled nursing care was provided as more than half of the care given in a 24-hour period for each of the four days of continuous care;
- the number of days of continuous home care requested for the extension; and
- documentation of the interdisciplinary team's discussion regarding alternate placement, including why continuous home care must be extended and why temporary alternate placement is not presently warranted.
- The continuous home care request will be denied if documentation is incomplete. Documentation mailed on or before the fifth consecutive day of the crisis period will be reviewed by DHS within 16 work hours of the time the documentation is received in the Long-Term Care Policy Section, at the address identified in paragraph (8)(A) of this subsection. Documentation mailed after the fifth consecutive day will be reviewed by DHS within 10 calendar days of the time the documentation is received in the Long-Term Care Policy Section, at the address identified in paragraph (8)(A) of this subsection.
- Multiple requests for extensions for the same period of crisis will not be considered. If multiple requests are received, DHS will consider only the first written request.
- DHS may extend continuous home care if it deems it medically necessary. Providers will be notified in writing of DHS's decision within the time frames outlined in paragraph (9) of this subsection after DHS's receipt of the written request and documentation at the address outlined in paragraph (8)(A) of this subsection. DHS will fax the response to the provider if the provider includes a fax number with the extension request.
- If DHS denies the request for an extension of continuous home care, the provider will be paid at the routine home care rate or inpatient care rate, if applicable, for subsequent days of care.
- Request for reconsideration. If the provider does not agree with DHS's denial of the request for an extension of continuous home care, the provider may request a reconsideration of the decision at the state office level. The written request for reconsideration and all supporting documentation must be submitted to DHS at the address in paragraph (8)(A) of this subsection no later than the tenth calendar day after the provider's receipt of the denial of the request for an extension. DHS's reconsideration will be limited to a review of the documentation submitted. DHS will complete the reconsideration no later than the tenth calendar day after receipt of the request for reconsideration.
(b) Respite care.
- Respite care is short-term inpatient care provided to the individual at home only when necessary to relieve the family members or other persons caring for the individual at home.
- Respite care may not be reimbursed for more than five consecutive days.
- Respite care can be provided by:
- a hospice that meets the condition of participation for providing inpatient care directly; or
- a hospital or nursing facility that also meets the Medicare standards regarding 24-hour nursing service and patient areas.
- Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time.
- Respite care may not be provided when the hospice patient is a nursing home resident.
(a) Medicaid hospice per diem rates. For each day that an individual is under the care of a hospice, the hospice will be reimbursed an amount applicable to the type and intensity of the services furnished to the individual for that day. For continuous home care, the amount of payment is determined based on the number of hours of continuous care furnished to the beneficiary on that day.
- Routine home care. The hospice will be paid the routine home care rate for each day the recipient is at home, under the care of the hospice, and not receiving continuous home care. This rate is paid without regard to the volume or intensity of routine home care services provided on any given day.
- Continuous home care. The hospice will be paid the continuous home care rate when continuous home care is provided. The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate. A minimum of 8 hours must be provided. For every hour or part of an hour of continuous care furnished, the hourly rate will be reimbursed to the hospice up to 24 hours a day. A maximum of five consecutive days are allowed for reimbursement. Additional days may be allowed with approval from the Department of Aging and Disability Services (DADS).
- Inpatient respite care. The hospice will be paid at the inpatient respite care rate for each day on which the beneficiary is in an approved inpatient facility and is receiving respite care. Payment for respite care may be made for a maximum of 5 days at a time including the date of admission but not counting the date of discharge. Payment for the sixth and any subsequent days is to be made at the routine home care rate.
- A hospice recipient who receives hospice respite care in a nursing facility and returns home after the respite does not have to be in a Medicaid bed in the nursing facility.
- Respite care days are subject to the limitation on total hospice inpatient care days, as outlined in subsection (h) of this section.
- If the hospice recipient dies as an inpatient, DADS pays the inpatient rate for the day of death.
- General Inpatient Care. Payment is made at the general inpatient rate when general inpatient care is provided.
- The Inpatient Care rate is paid for the date of admission and all subsequent inpatient days except day of discharge.
- For the day of discharge, DADS pays the routine home care rate.
- If the hospice recipient dies as an inpatient, DADS pays the inpatient rate for the day of death.
- Inpatient care days are subject to the limitation on total hospice inpatient care days, as outlined in subsection (h) of this section.
(b) Medicaid payments for physician services.
- The Medicaid Hospice Program makes payments to the Medicaid hospice provider for hospice physician services according to the customary and reasonable Texas Medicaid physician charges.
- The Medicaid Hospice Program does not pay when hospice physician services are provided by physicians who are not on staff with the Medicaid hospice provider or for independent contractors, who are under contract with the hospice.
- Payments for non-hospice physician services to Medicaid hospice recipients are made directly to physicians, physician assistants, or advanced practice nurses by Medicaid through DADS' claims processor.
- The Medicaid hospice provider must include physician services in the hospice plan of care and clinical records and must inform physicians on how to bill for services to hospice recipients.
(c) Medicaid hospice-nursing facility per diem rates. The Medicaid Hospice Program pays the Medicaid hospice provider a hospice-nursing facility rate that is 95% of the Medicaid nursing facility rate for each hospice recipient in a nursing facility to take into account the room and board furnished by the facility. When the hospice-nursing facility rate is paid to the hospice provider, Medicaid vendor payment to the nursing facility is not paid. Room and board services include performance of personal care services, including assistance in the activities of daily living, in socializing activities, administration of medication, maintaining the cleanliness of a resident's room, and supervision and assisting in the use of durable medical equipment and prescribed therapies.
(d) Medicaid hospice-intermediate care facilities for persons with mental retardation or related conditions (ICF/MR-RC) per diem rates. The Medicaid Hospice Program pays the Medicaid hospice provider ahospice-ICF/MR-RC rate that is 95% of the ICF/MR-RC rate for each hospice recipient in an ICF/MR-RC to take into account the room and board furnished by the facility. When the hospice-ICF/MR-RC rate is paid to the hospice provider, Medicaid vendor payment to the ICF/MR-RC is not paid. Room and board services include performance of personal care services, including assistance in the activities of daily living, in socializing activities, administration of medication, maintaining the cleanliness of a resident's room, and supervision and assisting in the use of durable medical equipment and prescribed therapies.
(e) Medicaid time limitations for DADS hospice payment.
- To receive payment of the hospice nursing facility rate, the hospice and nursing facility providers must have completed and submitted a Minimum Data Set (MDS) assessment for the hospice recipient or applicant.
- For a hospice recipient or applicant currently residing in the facility with a current MDS assessment, no action is required until the next required MDS assessment.
- For a hospice recipient or applicant newly admitted to the facility, the hospice and the nursing facility must complete and submit an MDS assessment as required by §19.801 of this title (relating to Resident Assessment).
- An MDS assessment received after the required date will have the stamp-in date as the effective date.
(f) Medicaid payments on Medicare coinsurance for drugs and biologicals. For Medicare-Medicaid recipients only, the Medicaid Hospice Program pays the Medicaid hospice provider a 5.0% coinsurance on prescription drugs and biologicals, not to exceed $5 per prescription.
(g) Medicaid payments for Medicare respite coinsurance. For Medicare-Medicaid recipients only, the Medicaid Hospice Program pays the hospice provider a 5.0% coinsurance for each day of respite care for up to five consecutive days of a hospice coinsurance period.
(h) Third-party resources. Medicaid pays only after all third-party resources have been used.
(i) Medicaid payment limitations for inpatient care. During the 12-month period beginning November 1 of each calendar year and ending October 31 of the following calendar year (the cap year), the aggregate number of inpatient hospice care days must not exceed 20% of the aggregate total number of all hospice care days for the same cap year. This limitation is applied once each year, at the end of the cap year for each Medicaid hospice provider. If it is determined that the inpatient rate should not be paid, any days for which the hospice receives payment at a home care rate are not counted as inpatient days. The limitation is calculated as follows:
- The maximum allowable number of inpatient days is calculated by multiplying the total number of days of Medicaid hospice care by 0.2.
- If the total number of days of inpatient care furnished to Medicaid hospice patients is less than or equal to the maximum, no adjustment is necessary.
- If the total number of days of inpatient care exceeds the maximum allowable number, the limitation is determined by:
- calculating a ratio of the maximum allowable days to the number of actual days of inpatient care and multiplying this ratio by the total reimbursement for inpatient care (general inpatient and inpatient respite reimbursement) that was made;
- multiplying excess inpatient care days by the routine home care rate;
- adding together the amounts calculated in subparagraphs (A) and (B) of this paragraph; and
- comparing the amount in subparagraph (C) of this paragraph with interim payments made to the hospice inpatient care during the "cap period."
- If the inpatient care maximum has been exceeded, DADS recoups excess payments from subsequent Medicaid hospice provider claims.
(a) Requirement for payment.
- To receive Medicaid hospice payments, a hospice must have a Medicaid hospice contract with the Department of Aging and Disability Services (DADS).
- To receive payment for providing Medicaid hospice services, a hospice must submit a complete and accurate claim for those services to DADS' claims processor. The claim must be received by DADS' claims processor within 12 months after the date of service. For purposes of this section, date of service is the last day of the month in which the service was provided.
If an individual's Medicaid eligibility for benefits is established after provision of services, the 12-month period for submission of claims starts on the date the individual's Medicaid eligibility was established.
(b) Submittal and forms completion requirements. To receive Medicaid hospice payments, the hospice must submit the following documents to DADS' claims processor:
- Texas Medicaid Hospice Program Recipient Election/Cancellation/Discharge Notice form, which must not have an election date that is earlier than the effective date of the hospice's Medicaid contract;
- Medicaid/Medicare Hospice Program Physician Certification of Terminal Illness form;
- Minimum Data Set (MDS) assessment, if applicable; and
- level of need (LON) form, if available.
(c) Denials. DADS denies the following claims submitted by a hospice:
- claims for hospice services provided before the effective date of the Medicaid hospice contract;
- claims for room and board provided before the effective date of the Medicaid hospice contract;
- claims for hospice services provided before the election date on the Texas Medicaid Hospice Program Election/Cancellation/Discharge Notice form and the Medicaid/Medicare Physician Certification of Terminal Illness form;
- claims for services provided after the individual has revoked his election of the Medicaid Hospice Program;
- claims for individuals who have been denied Medicaid eligibility and who were not eligible for Medicaid services when hospice services were provided;
- claims for individuals who are dually eligible for Medicaid and Medicare and were covered by the Medicare hospice benefit when services were provided; and
- claims for hospice services provided by a hospice after its Medicaid hospice contract has been terminated.
Procedural Requirements. The Texas Department of Human Services (DHS) will conduct contract management visits annually. The hospice provider must submit all information requested to DHS, as outlined in their contract.
The Texas Department of Human Services (DHS), as the operating agency for the Medicaid hospice program, may impose certain sanctions on the Medicaid hospice provider.
(a) The Department of Aging and Disability Services may take sanctions against a hospice for failure to comply with the terms of the contract, program rules, or both, as described in §49.61 of this title (relating to Sanctions).
(b) To appeal a sanction, a hospice must request a hearing from the Texas Health and Human Services Commission according to the provisions outlined in 1 TAC, Chapter 357, Subchapter I.
Referral to the Attorney General. Suspected or alleged Medicaid fraud will be referred to the Attorney General's office and the Health and Human Services Commission, Office of Investigations.
§30.90 Utilization Review and Control Activities Performed by Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Department.
(a) According to federal regulations and State Plan requirements, HHSC UR staff will conduct required on-site activities related to utilization review and control in nursing facilities receiving Medicaid reimbursement through the hospice provider for hospice services.
(b) Hospice provider staff must cooperate with HHSC UR staff during on-site inspections regarding personal contact with hospice recipients and the review of their clinical records.
(c) Subchapter I, Medical Review and Re-Evaluation, will go into effect on June 1, 2001.
The Department of Aging and Disability Services adopts by reference 1 TAC §371.212 (relating to Minimum Data Set Assessments) and §371.214 (relating to Resource Utilization Group Classification System). Each hospice provider must comply with the Texas Health and Human Services Commission's utilization review requirements found at 1 TAC §371.212 and §371.214.
(a) A hospice must document hospice services provided to an individual in a nursing facility or an intermediate care facility for persons with mental retardation or related conditions
(ICF/MR-RC) in the nursing facility clinical record or the ICF/MR-RC client record, and advise the nursing facility or ICF/MR-RC staff of changes in the individual's condition as necessary.
(b) A hospice provider must have joint procedures with the nursing facility or ICF/MR-RC for ordering medications that ensure the proper payer is billed and for reconciling billing between the nursing facility or ICF/MR-RC and hospice.
(c) An individual has the right to refuse any service provided by a nursing facility, ICF/MR-RC, or hospice.